Acute Achilles Tendon Rupture

Rupture, or tearing, of the Achilles tendon is a common condition. This typically occurs in the unconditioned individual who sustains the rupture while playing sports, or perhaps, from tripping. There is a vigorous contraction of the muscle and the tendon tears. The patient will often describe the sensation that someone or something has hit the back of the calf muscle. Pain is suddenly present, and although it is possible to walk, it is usually painful. More importantly however, the leg is weak. This is particularly noticeable when trying to push off while walking, and there is not sufficient strength to do so.

	The diagnosis of a rupture of the Achilles tendon is easy to make, and no XR, MRI or other test is necessary. The defect in the tendon is easy to see and to palpate as seen in this picture.
Diagnosis of rupture of the tendon is easily made by your orthopedic surgeon, and in this patient one can see the defect in the end of the leg when the tendon has ruptured.

Non surgical care

While it is possible to treat this ruptured tendon without surgery, this is not ideal since the maximum strength of the muscle and tendon rarely returns. The reason for this is that the ends of the tendon are ruptured in a very irregular manner, almost like the ends of a paint brush. As soon as the tendon ruptures, the calf muscle (gastrocnemius muscle) continues to pull on the tendon, and the end of the ruptured tendon pulls back into the leg, which we call retraction. Once the tendon retracts, it is never possible to get sufficient strength back without surgery, because the muscle no longer functions at the correct biomechanical length, and is now stretched out.

If for one reason or another your doctor does not recommend surgery, it is essential to obtain special tests to check that the ends of the tendon are lying next to each other so that healing can occur. The best test to do this is called an ultrasound, and not an MRI.

There are patients for whom surgery cannot be performed, in particular, due to existing medical conditions which may add to potential for complications following surgery. For these patients, we use a specially designed boot which positions the foot correctly, and takes the pressure and tension off the muscle and tendon. Most importantly however, a cast is never used because it causes permanent shrinkage (atrophy) of the calf muscle. We use a special boot, which permits pressure on the foot with walking, and a hinge is incorporated into the boot to permit movement of the ankle. We have demonstrated in many studies of rupture of the Achilles tendon, that this movement of the foot in the boot while walking is ideal for tendon healing.

Many years ago, patients with a rupture of the Achilles were placed in a cast in order to heal the tendon. This is no longer used, since the case increases the likelihood of another rupture of the tendon, and creates stiffness of the ankle, and weakness of the leg muscles.

The rupture of the Achilles tendon is shown here. Note the very long cut on the back of the leg. This is an old fashioned operation. Now we are able to perform the surgery through a tiny one-inch incision on the back of the leg.

There are old fashioned techniques for repairing the tendon which require very long incisions (eight inches) on the back of the leg. These are complicated and associated with a high incidence of infection in the skin after surgery. This is an important consideration, since infection in the skin can lead to devastating problems with the skin and tendon. This problem of skin infection has, in the past, led surgeons away from surgical methods of treatment.

Here you can see that the tendon ends have been approximated with stitches. This is a large cut on the leg, and nowadays is not necessary

Fortunately, now there is a new, unique method available for operating on and repairing the tendon. This new method requires only a tiny incision of one to two centimeters in length. This is far more accurate surgery. Recovery after this procedure is easier and the surgical complication rate is extremely low.

Note the absence of scars in this patient. The stitches were inserted through tiny punctures in the skin, The patient is standing on tip toes three months following her surgery, and has begun a training program to resume ball sports

Rehabilitation after Achilles tendon surgery

Following the tendon repair no walking on the foot is permitted for ten days. Then walking is begun in a removable boot. There were some treatments used many years ago that relied upon a leg cast. This led to tremendous weakness and atrophy of muscle that was often permanent. Approximately fifteen years ago, with a treatment pioneered by Dr. Myerson, the recovery after surgery for repairing the Achilles tendon changed dramatically, leading to maximum restoration of tendon healing and rapid return of strength. Instead of a cast, a removable boot is worn and instead of using crutches, walking is commenced very rapidly after surgery. Therapy and exercises are begun soon after surgery. This therapy process is critical in the recovery after tendon rupture, and without a carefully monitored program, full recovery is never possible. This treatment has made a huge difference in the recovery process for both recreational and professional athletes.

The rupture of the Achilles tendon here was treated with a short incision and this patient is able to stand on tip toes at 8 weeks after surgery. Rehabilitation with exercise is very important early on after surgery to maximize strength.